Health Priorities of Multi-Morbid Ambulatory Patients in New York City During the COVID-19 Pandemic: A Qualitative Analysis.

During the COVID-19 pandemic, adults with chronic conditions delayed or avoided seeking preventative and general medical care, leading to adverse consequences for morbidity and mortality. In order to bring patients back into care, we, in this qualitative study, sought to understand the foremost health-related needs of our multi-morbid ambulatory patients to inform future outreach interventions. Via a telephone-based survey of our high-risk patients, defined using a validated EPIC risk model for hospitalization and ED visits, we surveyed 214 participants an open-ended question, "What is your top health concern that you would like to speak with a doctor or nurse about". We found 4 major themes: 1) primary care matters, 2) disruptions in health care, 3) COVID-19's impact on physical and mental health, and 4) amplified social vulnerabilities. Our results suggest that interventions that reduce barriers to preventative services and disruptions to healthcare delivery are needed.

Factors Associated with Never Having Had A Video Visit.

INTRODUCTION: Disparities in access to video-visit services have been described during the COVID-19 pandemic. Thus, we aimed to examine factors associated with not having a video-visit among a medically high-risk ambulatory population. METHODS: In this cross-sectional study, our telephone-based survey was designed to understand the health-related challenges, social needs, and access to and attitudes toward video-visit. RESULTS: In the multivariable analysis, having fewer symptoms unrelated to COVID, more barriers to medications, and less confidence with video-visit software were significantly associated with an increased prevalence of not having a video-visit. CONCLUSIONS: Our findings suggest that additional efforts are needed to eliminate disparate video-visit use.

Development of a Practice-based Community Outreach Intervention to Prevent Inequities in COVID-19 Vaccinations.

Despite disproportionately higher rates of morbidity and mortality from COVID-19 among Black and Hispanic adults in the United States, ethnoracial disparities in vaccination rates emerged rapidly. The objective of this quality improvement study was to rapidly develop and implement an equity-focused community outreach intervention that facilitated COVID-19 vaccine appointments. Using the Plan-Do-Study-Act model, this multipronged, primary care-based outreach intervention developed call/recall systems that addressed vaccine hesitancy and facilitated real-time vaccine scheduling. Through 5058 calls to 2794 patients, 1519 patients were successfully reached. Of the 750 patients eligible for vaccine scheduling, 129 (17.2%) had a vaccine appointment scheduled by the caller and 72 (9.6%) indicated a plan to self-schedule. Low confidence in the vaccine was the most cited reason for declining assistance with a vaccine appointment. Primary care practices may wish to consider introducing similar outreach interventions in the future to address ethnoracial inequities in vaccination distribution.

The Cough Cold and Fever Clinic: A Model for the Safe Management of Ambulatory Patients With Suspected COVID-19.

BACKGROUND AND OBJECTIVE: When the coronavirus disease-2019 (COVID-19) pandemic swept through New York City, hospital systems became quickly overwhelmed and ambulatory strategies were needed. We designed and implemented an innovative program called the Cough Cold and Fever (CCF) Clinic to safely triage, evaluate, treat, and follow up patients with symptoms concerning for COVID-19. METHODS: The CCF Clinic was launched on March 13, 2020, in the ambulatory internal medicine office of New York Presbyterian-Weill Cornell Medicine. Patients with symptoms suspicious for COVID-19 were first triaged via telemedicine to determine necessity of in-person evaluation. Clinic workspaces and workflows were fashioned to minimize risk of viral transmission and to conserve COVID-19 testing supplies and personal protective equipment. Protocols containing the most recent COVID-19 practice guidelines were created, updated regularly, and communicated through twice-daily huddles and as a shareable online document. Discharged patients were followed up for at least 7 days through telemedicine. Patient outcomes, including admission to the emergency department (ED), hospitalization, and death, were tracked to ensure clinical quality. RESULTS: We report on the first 620 patients seen at CCF between March 13, 2020, and June 19, 2020. Telemedicine follow-up was achieved for 500 (81%). We tested 347 (56%) patients for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), with 119 (34%) testing positive. Forty-seven (8%) patients were sent to the ED directly from the CCF Clinic and 42 (89%) of these were admitted. Of the patients discharged home from CCF, 15 (3%) were later admitted to a hospital. Twelve (2%) patients in total died. CONCLUSION: The vast majority of patients, over 90%, seen in CCF were discharged home, with only a small percentage (3%) later requiring admission to a hospital. Of the patients sent directly to the ED from CCF, close to 90% were admitted, verifying the accuracy of our triage. Overall mortality was low (2%), especially when compared with mortality rates in New York City during the pandemic peak. Telemedicine was effective in identifying patients in need of in-person evaluation and in tracking and follow-up. Workflows and protocols were adaptable to reflect rapidly changing resources and clinical guidelines. Frequent communication through a diversity of methods was critical. Through these strategies, we were able to create a safe and effective outpatient program for patients with potential COVID-19.

The impact of a faculty development program, the Leadership in Academic Medicine Program (LAMP), on self-efficacy, academic promotion and institutional retention.

BACKGROUND: Academic medical centers invest considerably in faculty development efforts to support the career success and promotion of their faculty, and to minimize faculty attrition. This study evaluated the impact of a faculty development program called the Leadership in Academic Medicine Program (LAMP) on participants' (1) self-ratings of efficacy, (2) promotion in academic rank, and (3) institutional retention. METHOD: Participants from the 2013-2020 LAMP cohorts were surveyed pre and post program to assess their level of agreement with statements that spanned domains of self-awareness, self-efficacy, satisfaction with work and work environment. Pre and post responses were compared using McNemar's tests. Changes in scores across gender were compared using Wilcoxon Rank Sum/Mann-Whitney tests. LAMP participants were matched to nonparticipant controls by gender, rank, department, and time of hire to compare promotions in academic rank and departures from the organization. Kaplan Meier curves and Cox proportional hazards models were used to examine differences. RESULTS: There were significant improvements in almost all self-ratings on program surveys (p < 0.05). Greatest improvements were seen in "understand the promotions process" (36% vs. 94%), "comfortable negotiating" (35% vs. 74%), and "time management" (55% vs. 92%). There were no statistically significant differences in improvements by gender, however women faculty rated themselves lower on all pre-program items compared to men. There was significant difference found in time-to-next promotion (p = 0.003) between LAMP participants and controls. Kaplan-Meier analysis demonstrated that LAMP faculty achieved next promotion more often and faster than controls. Cox-proportional-hazards analyses found that LAMP faculty were 61% more likely to be promoted than controls (hazard ratio [HR] 1.61, 95% confidence interval [CI] 1.16-2.23, p-value = 0.004). There was significant difference found in time-to-departure (p < 0.0001) with LAMP faculty retained more often and for longer periods. LAMP faculty were 77% less likely to leave compared to controls (HR 0.23, 95% CI 0.16-0.34, p < 0.0001). CONCLUSIONS: LAMP is an effective faculty development program as measured subjectively by participant self-ratings and objectively through comparative improvements in academic promotions and institutional retention.

A Symptom-Directed Paradigm for the Evaluation and Management of Upper Respiratory Tract Infections.

Upper respiratory tract infections are one of the most common challenges in ambulatory medicine. Effective evaluation involves identification, primarily through the history, of the dominant set of patient symptoms leading to accurate diagnosis. Certain more morbid illnesses that mimic common upper respiratory symptoms can also be excluded with this approach. Treatment should address patient preferences through an understanding of the limited utility of antibiotics and through tailored advisement of the numerous pharmacologic options for symptom relief.

Implementation of Video Visits During COVID-19: Lessons Learned From a Primary Care Practice in New York City.

Background: During the height of the coronavirus (COVID-19) pandemic, there was an unprecedented demand for "virtual visits," or ambulatory visits conducted via video interface, in order to decrease the risk of transmission. Objective: To describe the implementation and evaluation of a video visit program at a large, academic primary care practice in New York, NY, the epicenter of the COVID-19 pandemic. Design and participants: We included consecutive adults (age > 18) scheduled for video visits from March 16, 2020 to April 17, 2020 for COVID-19 and non-COVID-19 related complaints. Intervention: New processes were established to prepare the practice and patients for video visits. Video visits were conducted by attendings, residents, and nurse practitioners. Main measures: Guided by the RE-AIM Framework, we evaluated the Reach, Effectiveness, Adoption, and Implementation of video visits. Key results: In the 4 weeks prior to the study period, 12 video visits were completed. During the 5-weeks study period, we completed a total of 1,030 video visits for 817 unique patients. Of the video visits completed, 42% were for COVID-19 related symptoms, and the remainder were for other acute or chronic conditions. Video visits were completed more often among younger adults, women, and those with commercial insurance, compared to those who completed in-person visits pre-COVID (all p < 0.0001). Patients who completed video visits reported high satisfaction (mean 4.6 on a 5-point scale [SD: 0.97]); 13.3% reported technical challenges during video visits. Conclusions: Video visits are feasible for the delivery of primary care for patients during the COVID-19 pandemic.

Tai chi for enhanced inpatient mobilization: A feasibility study.

OBJECTIVE: To determine whether utilizing beginner, video-guided tai chi and qigong classes as an adjunct to physical therapy to enhance mobilization among hospitalized patients is feasible and acceptable. DESIGN: Single-arm feasibility study over a 15½-week period. SETTING: Three medical-surgical units at one hospital. INTERVENTIONS: Small-group video-guided beginner-level tai chi and qigong classes supervised by physical therapists occurred three times a week. MAIN OUTCOME MEASURES: The primary outcome was weekly class attendance. Secondary outcomes included patient and staff satisfaction, collected by surveys and semi-structured interviews. Process measures included class duration. Balancing measures included falls. RESULTS: One-hundred and fifty-seven patients were referred for recruitment, 45 gave informed consent, and 38 patients attended at least one class. The number of weekly class attendees increased during the study period. Based on first-class experience, 68% (26/38) of patients reported enjoying the class "quite a bit" or "extremely," 66% (25/38) of patients reported feeling "more mobile" afterward, and 76% (29/38) of patients agreed that the class made them more comfortable going home. Average class duration was 29 minutes. Zero falls occurred during or immediately following class. CONCLUSIONS: Video-guided tai chi and qigong classes are feasible and well-received at our hospital. Future studies of the impact on preserving mobility and function or reducing length of stay are of interest.

Decision Support for Joint Replacement: Implications for Decisional Conflict and Willingness to Undergo Surgery.

Objectives: The present study investigates age differences in the types of decision support that total joint replacement (TJR) candidates desire and receive when making the decision to pursue surgery. We consider the social structural (relationship to the patient) and experiential factors (network members' experience with TJR) that influence individuals' support preferences and the interactions of these factors with age. We also examine whether a lack of support is linked with increased decisional conflict and reduced willingness to undergo surgery. Method: A telephone survey was conducted with 100 individuals (aged 40+) who were contemplating knee or hip replacement. Results: TJR candidates desired and received decision support from health care providers, family members, and individuals who had previously undergone TJR. They reported higher deficits in informational and emotional support than in instrumental support. Overall, a lack of instrumental support was associated with greater decisional conflict; a lack of instrumental support and a lack of informational support were associated with reduced willingness to undergo TJR. Discussion: Our findings point to the importance of involving both formal and informal network members in TJR discussions, and the need for informational guidance and practical assistance to reduce decisional conflict and uncertainty among individuals considering TJR.

Rapid Primary Care Follow-up from the ED to Reduce Avoidable Hospital Admissions.

INTRODUCTION: Hospital admissions from the emergency department (ED) now account for approximately 50% of all admissions. Some patients admitted from the ED may not require inpatient care if outpatient care could be optimized. However, access to primary care especially immediately after ED discharge is challenging. Studies have not addressed the extent to which hospital admissions from the ED may be averted with access to rapid (next business day) primary care follow-up. We evaluated the impact of an ED-to-rapid-primary-care protocol on avoidance of hospitalizations in a large, urban medical center. METHODS: We conducted a retrospective review of patients referred from the ED to primary care (Weill Cornell Internal Medicine Associates - WCIMA) through a rapid-access-to-primary-care program developed at New York-Presbyterian / Weill Cornell Medical Center. Referrals were classified as either an avoided admission or not, and classifications were performed by both emergency physician (EP) and internal medicine physician reviewers. We also collected outcome data on rapid visit completion, ED revisits, hospitalizations and primary care engagement. RESULTS: EPs classified 26 (16%) of referrals for rapid primary care follow-up as avoided admissions. Of the 162 patients referred for rapid follow-up, 118 (73%) arrived for their rapid appointment. There were no differences in rates of ED revisits or subsequent hospitalizations between those who attended the rapid follow-up and those who did not attend. Patients who attended the rapid appointment were significantly more likely to attend at least one subsequent appointment at WCIMA during the six months after the index ED visit [N=55 (47%) vs. N=8 (18%), P=0.001]. CONCLUSION: A rapid-ED-to-primary-care-access program may allow EPs to avoid admitting patients to the hospital without risking ED revisits or subsequent hospitalizations. This protocol has the potential to save costs over time. A program such as this can also provide a safe and reliable ED discharge option that is also an effective mechanism for engaging patients in primary care.

Improving Communication With Surrogate Decision-Makers: A Pilot Initiative.

BACKGROUND: Difficult conversations in medical care often occur between physicians and patients' surrogates, individuals entrusted with medical decisions for patients who lack the capacity to make them. Poor communication between patients' surrogates and physicians may exacerbate anxiety and guilt for surrogates, and may contribute to physician stress and burnout. OBJECTIVE: This pilot study assesses the effectiveness of an experiential learning workshop that was conducted in a clinical setting, and aimed at improving resident physician communication skills with a focus on surrogate decision-making. METHODS: From April through June 2016, we assessed internal medicine residents' baseline communication skills through an objective structured clinical examination (OSCE) with actors representing standardized surrogates. After an intensive, 6-hour communication skills workshop, residents were reassessed via an OSCE on the same day. A faculty facilitator and the surrogate evaluated participants' communication skills via the expanded Gap Kalamazoo Consensus Statement Assessment Form. Wilcoxon signed rank tests (α of .05) compared mean pre- and postworkshop scores. RESULTS: Of 44 residents, 33 (75%) participated. Participants' average preworkshop OSCE scores (M = 3.3, SD = 0.9) were significantly lower than postworkshop scores (M = 4.3; SD = 0.8; Z = 4.193; P < .001; effect size r = 0.52). After the workshop, the majority of participants self-reported feeling "more confident." CONCLUSIONS: Residents' communication skills specific to surrogate decision-making benefit from focused interventions. Our pilot assessment of a workshop showed promise, and additionally demonstrated the feasibility of bringing OSCEs and simulated encounters into a busy clinical practice.

Using peer-assisted learning to teach and evaluate residents' musculoskeletal skills.

Although direct observation and corrective feedback are established methods of increasing select aspects of residents' musculoskeletal (MSK) clinical skills, the evaluation and management of patients with MSK complaints remains an underemphasized part of internal medicine training. This paper reports on the development of an innovative peer-assisted learning (PAL) model to teach five MSK areas (back, knee, shoulder, neck, or hip pain). Based on data from 42 participating interns and 44 senior residents from an urban US academic medical center, results from an objective structured clinical exam (OSCE) demonstrate gains in both knowledge and self-reported confidence in MSK skills. Moreover, subsequent focus group results reveal a strong preference for the PAL model. In conclusion, an educational module that utilizes the OSCE format holds much promise for teaching MSK skills to both intern and senior residents.

Induction of centrosome amplification by formaldehyde, but not hydroquinone, in human lymphoblastoid TK6 cells.

Benzene and formaldehyde (FA) are important industrial chemicals and environmental pollutants that cause leukemia by inducing DNA damage and chromosome aberrations in hematopoietic stem cells (HSC), the target cells for leukemia. Our previous studies showed that workers exposed to benzene and FA exhibit increased levels of aneuploidy in their blood cells. As centrosome amplification is a common phenomenon in human cancers, including leukemia, and is associated with aneuploidy in carcinogenesis, we hypothesized that benzene and FA would induce centrosome amplification in vitro. We treated human lymphoblastoid TK6 cells with a range of concentrations of hydroquinone (HQ, a benzene metabolite) or FA for 24 h, allowed the cells to recover in fresh medium for 24 h, and examined centrosome amplification; chromosomal gain, loss, and breakage; and cytotoxicity. We included melphalan and etoposide, chemotherapeutic drugs that cause therapy-related acute myeloid leukemia and that have been shown to induce centrosome amplification as well as chromosomal aneuploidy and breakage, as positive controls. Melphalan and etoposide induced centrosome amplification and chromosome gain and breakage in a dose-dependent manner, at cytotoxic concentrations. HQ, though cytotoxic, did not induce centrosome amplification or any chromosomal aberration. FA-induced centrosome amplification and cytotoxicity, but did not induce chromosomal aberrations. Our data suggest, for the first time, that centrosome amplification is a potential mechanism underlying FA-induced leukemogenesis, but not benzene-induced leukemogenesis, as mediated through HQ. Future studies are needed to delineate the mechanisms of centrosome amplification and its association with DNA damage, chromosomal aneuploidy and carcinogenesis, following exposure to FA.

Formaldehyde induces micronuclei in mouse erythropoietic cells and suppresses the expansion of human erythroid progenitor cells.

Although formaldehyde (FA) has been classified as a human leukemogen, the mechanisms of leukemogenesis remain elusive. Previously, using colony-forming assays in semi-solid media, we showed that FA exposure in vivo and in vitro was toxic to human hematopoietic stem/progenitor cells. In the present study, we have applied new liquid in vitro erythroid expansion systems to further investigate the toxic effects of FA (0-150 µM) on cultured mouse and human hematopoietic stem/progenitor cells. We determined micronucleus (MN) levels in polychromatic erythrocytes (PCEs) differentiated from mouse bone marrow. We measured cell growth, cell cycle distribution, and chromosomal instability, in erythroid progenitor cells (EPCs) expanded from human peripheral blood mononuclear cells. FA significantly induced MN in mouse PCEs and suppressed human EPC expansion in a dose-dependent manner, compared with untreated controls. In the expanded human EPCs, FA slightly increased the proportion of cells in G2/M at 100 µM and aneuploidy frequency in chromosomes 7 and 8 at 50 µM. Our findings provide further evidence of the toxicity of FA to hematopoietic stem/progenitor cells and support the biological plausibility of FA-induced leukemogenesis.

Bridging care transitions: findings from a resident-staffed early postdischarge program.

PROBLEM: Academic medical centers face unique challenges to ensuring patient safety after a hospital discharge, including those related to providing patient follow-up care in practices staffed by residents who are not comfortable managing care transitions. APPROACH: In 2011, the authors designed a quality improvement program for early postdischarge follow-up (bridge visits) at a resident primary care outpatient practice, using existing resources. The authors added a unique appointment template to the outpatient electronic health record to guide residents during the visit. Residents completed both postvisit and postprogram surveys regarding their experience with the program, and patients completed postvisit phone surveys regarding their satisfaction with the program. OUTCOMES: Fifty-eight residents completed postvisit surveys, of which 31.0% (18/58) reported problems with medication reconciliation and 25.9% (15/58) with adherence to discharge medications. Of those residents who completed postprogram surveys, almost half (18/38; 47.4%) agreed that their experience changed the way they discharge patients. Nearly all patients who responded to the postvisit phone surveys reported that the program reinforced their discharge and medication instructions (44/46; 95.7%); 81.8% (18/22) of patients with established providers did not mind seeing an interim physician for expedited postdischarge care. NEXT STEPS: An early postdischarge program at a resident outpatient primary care practice is valuable both in ensuring patient safety and as a model to promote experiential learning in medical education. Findings from this study will be used to develop a formal curriculum in care transitions for all residents.

Temporal horizons in pain management: understanding the perspectives of physicians, physical therapists, and their middle-aged and older adult patients.

PURPOSE: The management of chronic noncancer pain (CNCP) involves trade-offs between immediate and delayed consequences of various treatments. Temporal trade-offs may be particularly salient for older adults because of age-related differences in prognosis and perceptions of future time. This study examined how perceptions of time influence the management of CNCP among patients and providers with particular emphasis on age differences. DESIGN AND METHODS: Focus groups were conducted with 28 CNCP patients (5 groups), 21 physicians (4 groups), and 23 physical therapists (3 groups). Audiotapes were transcribed and analyzed using standard qualitative methods. RESULTS: Analyses identified multiple aspects of time perceptions that are relevant to the management of CNCP: the long-term prognosis, the time horizon used for concrete treatment planning, and concerns about future side effects. Although there was some overlap, these aspects showed divergent patterns across age groups and between patients and providers. Patients and providers agreed that pain is more stable and chronic in older adults. Time horizons in treatment planning differed between patients who were present-focused and providers who were focused on longer term effects, but treatment horizons did not differ by patient age. Finally, although providers were more concerned about future side effects in older people, patients' concerns did not differ by age. IMPLICATIONS: Time horizons have practical implications for the quality of the patient-provider relationship and self-management of CNCP. A better understanding of the underlying mechanisms could inform interventions to reduce age disparities in pain care.